Provider Demographics
NPI:1568916534
Name:MOFFITT, MICHELLE (RSW)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2121
Mailing Address - Country:US
Mailing Address - Phone:318-657-0804
Mailing Address - Fax:
Practice Address - Street 1:2401 WEST ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11568916534Medicaid
LA1568916534Medicaid